1. Female Reproductive Anatomy
   1. Internal
      1. Adnexa
         1. Ovaries
            1. Outer surface
            2. Simple cuboidal epithelium
            3. Function
            4. Convert cholesterol into androstenedione and testosterone
            5. Desmolase
            6. Regulation
            7. LH
            8. Function
            9. Convert thecal androgens into estrone and estradiol
            10. Aromatase
            11. Regulation
            12. FSH
         2. Fallopian tubes
            1. Simple ciliated columnar epithelium
            2. Fallopian Tube occlusion
         3. Ligaments
         4. Wolffian vestiges
      2. Uterus
         1. Regions
         2. Layers
            1. Endometrium
            2. Functional layer
            3. Simple columnar epithelium with long tubular glands in proliferative phase
            4. Coiled glands in secretory phase
            5. Basal layer
            6. Gestational Changes
            7. Trophoblastic remodeling of spiral arteries
            8. Failure results in preeclampsia
            9. Stomal decidualization
            10. Eosinophilic stromal cytoplasm
            11. Arteries more prominent
            12. Hypersecretory changes
            13. Glandular infolding
            14. Intracellular vacuoles
            15. Arias-Stella reaction
            16. Hobnail cells
            17. Nuclear atypia
            18. Hyperchromasia
            19. Myometrium
            20. Perimetrium
            21. Parametrium
         3. Ligaments
         4. Uterine glands
      3. Vagina
         1. Vaginal fornix
         2. Hymen
   2. External
      1. Vulva
         1. Labia
         2. Clitoris
         3. Urethra
2. Female Reproductive Physiology
   1. Endometrial Physiology
      1. Proliferative phase of the endometrium
         1. Early: growth of glands, stoma, and blood vessels in the functionalis layer
         2. Late: pseudostratification and mitotic figures of the glands
      2. Secretory phase of the endometrium
         1. Early: formation of subnuclear vacuoles
         2. Middle: vacuoles emptied into gland lumens
         3. Late: stromal (pre/pseudo)decidualization
      3. Menstruation
         1. Condensed stroma aggregated into "blue balls"; separated from glands
         2. Neutrophils, necrotic cellls, apoptosis, and hemorrhage appear
      4. Effects of exogenous progesterone
         1. Gland atrophy
         2. Stromal proliferation/decidualization
         3. Venous dilation
   2. Menstrual cycle
      1. Menses
      2. Early Follicular/Proliferative Phase
         1. Begins on cycle day 1
         2. Key Events
            1. Follicle maturation
            2. Recruitment
            3. Selection
            4. Dominance
            5. Estrogen production
         3. Primary follicles
         4. Secondary follicle
         5. Uterine Cycle
         6. Hormonal Physiology
            1. FSH secretion
            2. Estrogen production
      3. Late Follicular/Proliferative Phase
         1. Begins 1-2 days before ovulation
         2. Key Events
            1. Oocyte meiosis resumption
         3. Mature (graafian) follicle
            1. Granulosa cells
            2. Aromatase expression
         4. Ovulation
         5. Corpus hemorrhagicum
         6. Uterine Cycle
         7. Hormonal Physiology
            1. Estrogen (>200 pg/mL)
            2. LH surge via positive feedback
            3. Androgen production
      4. Ovulation
         1. Most fertile part of the cycle
      5. Early Luteal/Secretory Phase
         1. Begins at ovulation
         2. Key Events
            1. Formation of corpus luteum
            2. Production of progesterone, inhibin A, and estrogen
         3. Corpus luteum
         4. Uterine Cycle
         5. Hormonal Physiology
            1. LH drives corpus luteum formation
            2. Progesterone production
            3. Estrogen production
            4. Inhibin A production
            5. Inhibition of FSH/LH production
      6. Late Luteal/Secretory Phase
      7. Luteal-Follicular Transition
         1. Lasts from end of one menstrual cycle to start of the next
         2. Key Events
            1. Degeneration of the corpus luteum
         3. Hormonal Physiology
            1. Progesterone and inhibin A production
            2. Increased FSH/LH production
         4. Clinical Associations
            1. Early rise in FSH
            2. Early inhibin decrease leads to early follicle recruitment
            3. Sign of diminishing ovarian reserve
      8. Luteal/Secretory Phase (14 days)
      9. Follicular/Proliferative Phase (variable duration)
      10. (Cycle days 0-4)
   3. Reproductive Development
      1. Embryological/Fetal Development
         1. Mesonephric (Wolffian) duct degenerates
         2. Paramesonephric (Mullerian) duct develops
            1. Fallopian tubes
            2. Uterus
            3. Upper portion of vagina
            4. Failure results in Mullerian agenesis (MRKH syndrome)
      2. Pubertal Development
         1. Normal onset: 8-13 years old
         2. Thelarche
            1. Breast development
            2. Tanner stage II
         3. Growth spurt
            1. Tanner stage II-III
         4. Menarche (age 12)
            1. Tanner stage IV
         5. Adrenarche/pubarche
            1. Hair growth
         6. Driven by adrenal glands
         7. Driven by hypothalamic/pituitary/ovarian axis
      3. Perimenopause (climacteric)
      4. Menopause
         1. Average onset: 51 years old
            1. Usually preceded by 4-5 years of abnormal menstual cycles
            2. Earlier onset in smokers
         2. Hormonal Changes
            1. Estrogen
            2. FSH
            3. due to lack of estrogen
            4. due to age-linked decline in number of ovarian follicles
            5. LH
            6. No surge
            7. GnRH
         3. Libido Changes
            1. Overall decrease in most women
            2. No fear of pregnancy
            3. Vulvovaginal atrophy and lack of sleep
      5. Postmenopause
      6. Menopausal Transition
         1. Time of menstrual cycle variability preceding final period
   4. Oogenesis
      1. Oogonium
         1. Diploid (2N, 2C)
      2. Replication (S phase)
      3. Primary oocyte
         1. Diploid (2N, 4C)
      4. Arrested in prophase I until ovulation
         1. Germinal vesicle
      5. Meiosis I
         1. Polar body
            1. Can degenerate or give rise to two polar bodies
      6. Secondary oocyte
         1. Haploid (1N, 2C)
      7. Arrested in metaphase II until fertilization
      8. Meiosis II
         1. Polar body
      9. Ovum
         1. Haploid (1N, 1C)
      10. 1st Trimester in utero to puberty
   5. Developmental Physiology
      1. Fertilization
      2. Oocyte activation
      3. Zygote
      4. Cleavage
         1. Division of cells in early embryo
            1. Produces a cluster the same size as the original zygote
            2. Blastomeres
      5. Morula
         1. 3-4 days post-fertilization
         2. Early stage embryo consisting of blastomeres in a solid ball
      6. Blastocyst
         1. 5 days post-fertilization
         2. Early stage embryonic stage following development of fluid-filled cavity in morula
         3. Outer cell layer/trophoectoderm (trophoblasts)
         4. Inner cell mass (embryoblasts)
         5. Blastocyst cavity (blastocoele)
      7. Implantation
         1. 6-10 days post-fertilization
      8. Bilaminar disc
         1. 12 days post-fertilization
         2. Trophoblastic derivatives
            1. Cytotrophoblast
            2. Syncytiotrophoblast
            3. Intermediate trophoblast
         3. Embryoblast derivatives
            1. Hypoblast (primitive endoderm)
            2. Epiblast (primitive ectoderm)
      9. Gastrulation
      10. Trilaminar embryo
          1. Week 3 post-fertilization
          2. Hypoblastic derivatives
             1. Primitive yolk sac
          3. Epiblastic derivatives
             1. Amniotic cavity
             2. Primitive germ layers
             3. Ectoderm
             4. Mesoderm
             5. Endoderm
      11. Neuralation
      12. Neurula
          1. Week 4 post-fertilization
      13. Somitogenesis
      14. Fetus
          1. Fetal Circulation
             1. Umbilical vessels
             2. Umbilical vein
             3. Carry oxygen and nutrients to fetus
             4. Umbilical artery
             5. Carry oxygen and nutrients away from fetus
   6. Gestational physiology
      1. Cardiovascular changes
         1. Changes in cardivascular physiology
            1. Heart rate
            2. Can be dangerous if patient has mitral stenosis
            3. Stroke volume
            4. Cardiac output
            5. Lower than expected in preeclampsia
            6. due to increased vascular permeability
            7. Blood pressure
            8. Progesterone-mediated vasodilation
            9. Systemic vascular resistance
            10. Higher than expected in preeclampsia
            11. due to vasospasm
            12. Systolic flow murmur
         2. Changes in cardiac anatomy
            1. Upward displacement of heart
      2. Renal changes
         1. Changes in renal physiology
            1. GFR
            2. Renal plasma flow
            3. Creatinine
            4. Urinary excretion of glucose and protein
            5. Na+ and K+ retnetion
            6. blood volume
         2. Changes in kidney anatomy
            1. size
            2. blood flow due to increased blood volume
      3. Gastrointestinal changes
         1. Changes in GI physiology
            1. GI motility
      4. Respiratory changes
         1. Changes in respiratory physiology
            1. Chronically low PaCO2
            2. CO2 excretion/breath
            3. Tidal volume
            4. No change in respiratory rate
            5. Minute ventilation
      5. Hematologic changes
         1. Changes in hematologic physiology
            1. Total RBC volume
            2. EPO
            3. Total plasma volume
            4. RAAS activation
            5. Hemoglobin
            6. Hematocrit
            7. Fibrinogen
            8. D-dimer
            9. Increase in plasma volume > increase in RBC volume
      6. Liver/Biliary changes
         1. Expected Labs
            1. Alk-phos
      7. Metabolic changes
         1. Serum cholesterol and triglycerides
            1. Lipid panels are rarely performed
         2. Hepatic glucose production
         3. Fasting hypoglycemia
            1. Fetal-placental sink
         4. Insulin resistance
            1. High insulin and post-prandial glucose
      8. Thyroid changes
         1. Free T4
            1. Thyroxine-binding globulin (TBG)
            2. Placental iodinase degrades T4 and T3
         2. TSH
            1. due to hCG stimulation TSH receptor
      9. Complications of Pregnancy
         1. Gestational diabetes
         2. Striae (stretch marks)
         3. Melasma
            1. Hyperpigmentation (due to estrogen stimulation)
         4. Procoagulant state
            1. Venous stasis (due to hormonal vasodilation)
            2. Coagulation factors
            3. Endothelial damage
         5. Mild hydronephrosis
            1. Ureter compression by uterus
         6. Heartburn
         7. Constipation
         8. Gastric fullness
         9. Hemorrhoids
            1. Compression of pelvic vessels by enlarging fetus
         10. Preeclampsia
   7. Parturition
      1. Stages of labor
         1. Onset of contractions
         2. First stage: latent phase
         3. Cervix dilated to 4 cm
         4. First stage: active phase
         5. Cervix dilated to 10 cm
            1. Complete dilation
         6. Second stage
         7. Delivery of infant
         8. Subtopic 8
         9. Delivery of placenta
      2. Cardinal movements of labor
         1. Engagement
         2. Descent
         3. Flexion
         4. Internal rotation
         5. Extension
         6. External rotation
         7. Explulsion
   8. Hormones
      1. GnRH
         1. GnRH secretion
            1. Pulsatile release
      2. FSH
         1. Signal Transduction
            1. cAMP via Gs-linked GPCR
      3. LH
         1. Signal Transduction
            1. cAMP via Gs-linked GPCR
      4. Estrogen
         1. Structure
            1. 17beta-Estradiol
            2. Ovary
            3. Estriol
            4. Placenta
            5. Estrone
            6. Adipose tissue
         2. Signal Transduction
         3. Function
            1. Developmental of genitalia and breast
            2. Growth of follicle
            3. Endometrial proliferation
            4. Myometrial excitability
            5. Regulation of Menstrual Cycle
            6. Upregluation of estrogen, LH, and progesterone receptors
            7. Feedback inhibition of FSH and LH
            8. LH surge
            9. Stimulation of prolactin secretion
            10. Transport proteins and SHBG
            11. Regulation of female fat distribution
            12. Regulation of lipid metabolism
            13. HDL
            14. LDL
      5. Progestins
         1. Structure
            1. Progesterone
         2. Signal Transduction
            1. Binds to progesterone receptor
         3. Function
            1. Stimulation ofendometrial glandular secretions and spiral artery development
            2. Maintenance of pregnancy
            3. myometrial excitability
            4. Production of thick cervical mucus
            5. Body temperature
            6. Inhibition of gonadotropins (LH, FSH)
            7. Inhibtion of prolactin
            8. Uterine smooth muscle relaxation
            9. Estrogen receptor expression
            10. Prevention of endometrial hyperplasia
      6. hCG
         1. Syncytiotrophoblast of placenta
         2. Structure
            1. Has identical alpha-subunit as LH, FSH, and TSH
            2. Has unique beta-subunit
            3. Pregnancy tests detect beta-subunit
         3. Function
            1. Maintains corpus luteum (and progesterone secretion) for the first 8-10 weeks of pregnancy
            2. Mimics LH
         4. Clinical Associations
            1. hCG
            2. Multiple gestations
            3. Hydatidiform moles
            4. Choriocarcinomas
            5. Down syndrome
            6. Hyperthyroidism
            7. hCG
            8. Ectopic/failing pregnancy
            9. Edward syndrome
            10. Patau syndrome
3. Clinical OBGYN
   1. Signs and Symptoms
      1. Menorrhagia and/or metrorrhagia
         1. Etiologies
            1. Structural
            2. Polyps
            3. Adenomyosis
            4. Leiomyoma
            5. Malignancy/hyperplasia
            6. Physiologic
            7. Coagulopathy
            8. Ovulatory dysfunction
            9. Endometrial (menses)
            10. Iatrogenic
            11. Not yet classified
         2. Menorrhagia
            1. Abnormally long or heavy menses
            2. Last >7 days or >80 mL of blood loss
         3. Metrorrhagia
            1. Frequent or irregular menses
         4. Menometrorrhagia
            1. Heavy, irregular menstruation
      2. Dysmenorrhea
         1. Pain with menses
         2. Etiologies
            1. Endometriosis
      3. Polymenorrhea
         1. <21-day cycle
      4. Oligomenorrhea
         1. >35-day cycle
         2. Etiologies
            1. Thyroid disease
            2. Hyperprolactinemia
            3. Non-classic congenital adrenal hyperplasia
            4. Androgen secreting tumor
            5. Cushing's disease
      5. Amenorrhea
         1. Absent menses
         2. Primary amenorrhea
            1. Lack of menses by age 13 with no secondary sex characteristics OR no menses by age 16 regardless of secondary sex characteristics
            2. Etiologies
            3. Chromosomal abnormalities
            4. 50%
            5. Turner's syndrome
            6. Hypothalamic dysfunction
            7. 20%
            8. Female Athlete Triad
            9. Amenorrhea/oligomenorrhea
            10. Osteoporosis/osteopenia
            11. Eating disorders
            12. Kallman's syndrome
            13. Anorexia
            14. Functional hypothalamic amenorrhea
            15. Absence of reproductive tract structures
            16. 15%
            17. Mayer-Rokitansky-Kuster-Hauser (MRKH) Syndrome
            18. Absence of uterus, cervix, and/or vagina
            19. Normal pubic hair
            20. Etiology
            21. Mullerian agenesis
            22. Membrane across vaginal opening
            23. 5%
            24. Transverse vaginal septum
            25. Imperforate hymen
            26. Pituitary disease
            27. 5%
            28. Other (PCOS, CAH, androgen insensitivity, hypothyroidism)
            29. 5%
            30. Primary amenorrhea with XY genotype
            31. Swyer syndrome
            32. Female secondary sex characteristics in an XY individual
            33. Etiology
            34. Gonadal dysgenesis due to lack of testes-determining factor
            35. 5-alpha reductase deficiency
            36. Natural History
            37. Ambiguous genitalia until puberty
            38. Puberty
            39. Growth and masculinization of external genitalia
            40. Normal internal genitalia
            41. Etiology
            42. Deficienct conversion of testosterone to DHT
            43. Androgen insensitivity syndrome
            44. Etiology
            45. Deficient/absent response of body cells to testosterone
         3. Secondary amenorrhea
            1. Etiologies
            2. Ovarian disease
            3. 40%
            4. Primary Ovarian Insufficiency
            5. Chemotherapy
            6. Galactosemia
            7. Fragile X premutation
            8. Hypothalamic dysfunction
            9. 35%
            10. Exercise-induced hypothalamic dysfunction
            11. Functional hypothalamic amenorrhea
            12. Anorexia
            13. Pituitary disease
            14. 19%
            15. Sheehan syndrome
            16. Amenorrhea
            17. Poor lactation
            18. Cold intolerance
            19. Etiology
            20. Pituitary ischemic infarct secondary to blood loss during/after childbirth
            21. Macroadenoma
            22. Hyperprolactinemia
            23. Uterine disease
            24. 5%
            25. Asherman's Syndrome
            26. Characterized by adhesions/synechiae and/or fibrosis of the endometrium
            27. Trauma
            28. Most commonly associated with dilation and curettage of the intrauterine cavity
            29. Treatment
            30. Surgical excision
            31. Hormone therapy
            32. Other (thyroid disease)
            33. 1%
            34. Polycystic Ovarian Syndrome
            35. Amenorrhea/oligomenorrhea
            36. Enlarged, bilateral cystic ovaries
            37. Hyperandrogenism
            38. Hirsutism
            39. fertility
            40. Acne
            41. Insulin resistance
            42. Treatment
            43. Weight reduction
            44. Oral contraceptives
            45. Clomiphene citrate
            46. Ketoconazole
            47. Spironolactone
            48. Metformin
            49. Most common cause of oligomenorrhea
      6. Blind or Absent Vagina
         1. Symptoms of obstructed menses
            1. Imperforate Hymen
            2. Transverse vaginal septum
            3. Can be distuished by asking patient to bear down
            4. Imperforate hymen should bulge out because it is thinner
         2. Asymptomatic
            1. Mullerian agenesis (MRKH syndrome)
            2. Androgen insensitivity syndrome
            3. Can be distinguished by presence/absence of pubic hair
            4. Normal pubic hair in Mullerian agenesis
            5. Scant/absent pubic hair in Androgen Insensitivity syndrome
      7. Obstruction of Fallopian Tube
         1. Proximal
         2. Distal
            1. Hydrosalpinx
            2. Filled with clear, serous fluid
            3. Pyosalpinx
            4. Filled with pus
            5. Hematosalpinx
            6. Filled with blood
            7. Appears distended on hysterosalpingogram
      8. Infertility
         1. Male Infertility
            1. Azoospermia
            2. Absence of sperm in semen
            3. Non-obstructive azoospermia
            4. Absence of sperm in semen due to abnormal production
            5. Pre-testicular azoospermia
            6. Hormonal dysfunction
            7. Testicular azoospermia
            8. Testicular failure
            9. Varicocele
            10. Obstructive (post-testicular) azoospermia
            11. Congenital Bilateral Absence of the Vas Deferens (CBAVD)
            12. CFTR mutations in cystic fibrosis
            13. Affects 98-99% of male CF patients
            14. Ejaculatory Duct Obstruction
            15. Vasectomy
            16. Aspermia
            17. Klinefelter's syndrome
            18. (47,XXY) male
            19. Tall, long extremities
            20. Eunuchoid body habitus
            21. Gynecomastia
            22. Female hair distribution
            23. Dysgenesis of seminiferous tubules
            24. Inhibin B
            25. FSH
            26. Abnormal Leydig cell function
            27. testosterone
            28. LH
            29. estrogen
            30. Retrograde ejaculation
            31. Ejaculatory Duct Obstruction
            32. Oligospermia
            33. < 20 million sperm/mL of semen
            34. Low sperm count
            35. Ejaculatory Duct Obstruction
            36. Asthenospermia
            37. sperm motility
            38. Teratospermia
            39. Abnormal morphology of sperm
      9. Chadwick's Sign
         1. Bluish tint to cervix
      10. Hegar's Sign
          1. Softening of the cervix
      11. Cervical dilation
      12. Cervial effacement
      13. Hot flashes
      14. Vaginal atrophy
      15. Sleep disturbances
      16. Osteoporosis
      17. Coronary artery disease
      18. Dyspareunia
          1. Difficult or painful sexual intercourse
          2. Etiologies
             1. Estrogen
             2. Menopause
          3. Local estrogen therapy
      19. Sexual activity
          1. Etiologies
             1. Lack of a partner
      20. Pulmonary Edema
          1. Etiologies
             1. Preeclampsia
      21. Cerebral or visual symptoms
          1. Etiologies
             1. Preeclampsia
      22. Proteinuria
          1. Etiologies
             1. Preeclampsia
      23. Hypertension
          1. Etiologies
             1. Preeclampsia
      24. Abnormal 1st trimester vaginal bleeding
          1. Etiologies
             1. Subchorionic hemorrhage
             2. Cervical/vaginal trauma
             3. Early pregnancy loss
             4. Ectopic pregnancy
             5. Molar pregnancy
             6. Placental implantation bleeding
      25. Loss of estrogen production
   2. Diagnostics and Workup
      1. Endometrial Sampling
         1. Biopsy
         2. Dilation and curettage (D&C)
      2. Labs
         1. FSH
            1. Abnormally elevated
            2. Abnormally decreased
            3. Physiologically elevated
            4. Menopause
         2. Urinary Ovulation Predictor test
            1. Measures LH in urine
         3. beta-hCG
         4. TSH
         5. Prolactin
         6. Testosterone
         7. 17-hydroxyprogesterone
         8. Estrogen
            1. Abnormally decreased
            2. FSH
            3. Hypothalamic dysfunction
            4. Pituitary dysfunction
            5. Physiologically decreased
            6. Menopause
         9. Platelets
            1. Abnormally decreased
            2. Preeclampsia
         10. Creatinine
             1. Abnormally elevated
             2. Preeclampsia
         11. Transaminases
             1. Abnormally elevated
             2. Preeclampsia
      3. Imaging Techniques
         1. Hysterosalpingogram
            1. X-ray or fluroscopy with contrast of uterine cavity and Fallopian tubes
         2. Dual-energy X-ray Absorptiometry (DEXA)
            1. T-score
            2. T-score <= -2.5
            3. Osteoporosis
            4. T-score -1 to -2.5
            5. Osteopenia
            6. T-score >= -1
            7. Normal
            8. Z-score
      4. Ovarian Reserve Testing
         1. Evaluate the capacity of ovary to provide viable eggs
         2. Methods
            1. Measure FSH levels
            2. Measure Anti-Mullerian hormone levels
            3. Count the number of 2-9 mm diameter antral follicles iwth ultrasound
      5. Genetic Testing
         1. Karyotype
         2. Microarray
            1. Array comparative genomic hybridization (aCGH)
            2. Detects copy number variations (CNVs)
            3. SNP array
            4. Detects single nucleotide polymorphisms (SNPs)
         3. Next-generation sequencing
         4. Pre-implantation Genetic Diagnosis (PGD)
            1. Identifies specific defects
         5. Pre-implantation Genetic Screening
            1. Identifies aneuploid embryos
         6. Genetic amplification
            1. Whole Genome Amplification
            2. Technique used to increase amount of a limited DNA sample
            3. Real-time qPCR
      6. Workup of suspected amenorrhea
         1. beta-hCG (pregnancy) Progestin challenge TSH (hypo/hyperthyroidism) FSH (ovarian failure) Prolactin (Hyperprolactinemia) Karyotype (Turner's syndrome) Testosterone (PCOS) Dexamethasone test (Cushing's disease) 17-hydroxyprogesterone (non-classical congenital adrenal hyperplasia) Hysteroscopy (outflow obstruction)
            1. Withdrawal bleed in progestin challenge Normal prolactin and TSH
            2. Anovulation
            3. Withdrawal bleed in progestin challenge
         2. Estrogen and progestin cycle
            1. Withdrawal bleed
            2. Hypoestrogenism
            3. Obtain MRI of pituitary gland
            4. Withdrawal bleed
            5. End organ process
            6. Nonreactive endometrium
            7. Uterine Outflow Tract obstruction
      7. Workup of infertility
         1. Semen analysis
            1. Volume
            2. Liquefaction time
            3. Sperm count
            4. Sperm motility
            5. Sperm morphology
            6. pH
            7. WBC count
            8. Fructose level
      8. Workup of Preterm Labor
         1. Vaginal swab
            1. Fetal fibronectin
            2. Suggests preterm labor
            3. Rules out preterm labor
            4. Crystallization (after evaporation)
            5. Suggests rupture of membranes
            6. Suggests no rupture of membranes
      9. Workup of suspected early pregnancy loss
         1. Ultrasound
            1. Detect structural abnormalities
         2. beta-hCG
            1. Determine pregnancy status
   3. The Expanded Gravita/Para System
      1. G(x)
         1. x = # of pregnancies
         2. Includes current pregnancy
      2. P(abcd)
         1. a = # of term deliveries
         2. b = # of preterm deliveries
         3. c = # of aborted pregnancies
         4. d = # of live births
   4. Antepartum Care
      1. Screening
         1. Nonstress Test
            1. Measures fetal heart rate (cardiotocography) and uterine contraction over 40 minute window
            2. Interpretation
            3. Reactive (normal)
            4. 2 or more fetal heart rate accelerations within a 20 minute period
            5. Nonreactive
            6. <2 fetal heart rate accelerations with a 20 minute period
         2. Fetal ultrasound
            1. Measures amniotic fluid volume
            2. Measures fetal tone
            3. Detects gross body movement
            4. Detects fetal breathing movements
         3. Contraction Stress Test
            1. Measures fetal tolerance to uterine contractions during delivery
            2. Interpretation
            3. Negative (normal)
            4. Positive
            5. Fetal heart rate decelerations
            6. Suggest poor fetal oxygenation
         4. Labs
            1. Complete blood count (CBC)
            2. Blood type, RH status and antibody screen
            3. STD screen (including HIV)
            4. Rubella titer/Varicella
            5. Group B Strep testing
            6. Aneuploidy testing
            7. Routine
            8. Optional
            9. Routine
            10. Optional
         5. Kick Counts
            1. Measured at 32 weeks
            2. Interpretation
            3. Normal: >= 10 kicks/hour for 3 hours in a day
            4. Follow-up with non-stress test and/or biphysical profile if results are not reasssuring
         6. Tracking Fetal Growth
            1. Measure fundal height
            2. Distance from pubic symphysis to top of uterus
            3. Should roughly equal weeks of gestation in centimeters (between 18-36 weeks)
         7. Genetic screening
            1. Autosomal recessive disorders
            2. Indicated only after parents are confirmed carriers
            3. General population screening
            4. Cystic Fibrosis
            5. Fragile X Syndrome
            6. Spinal muscular atrophy
            7. Population-based Carrier Screen Recommendations
            8. Hemoglobinopathies
            9. African
            10. Southeast Asian
            11. Mediterranean
            12. Lysosomal Storage Diseases
            13. Tay-Sachs Disease
            14. Ashkenazi Jews
         8. Amniocentesis
            1. Transabdominal sampling of amniotic fluid
            2. FISH, karyotype, or culture of floating fetal cells
            3. Genetic diagnosis
            4. Patau Syndrome (Trisomy 13)
            5. Down Syndrome (Trisomy 21)
            6. Edwards Syndrome (Trisomy 18)
            7. Fragile X Syndrome
            8. Inborn Errors of Metabolism
            9. Detection of neural tube defects
            10. Measure level of alpha-fetoprotein
            11. Interpretation
            12. alpha-fetoprotein suggests neural tube defect
            13. Estimation of lung maturity
         9. Chorionic villus sampling (CVS)
            1. Transcervical or transabdominal sampling of chorionic villi
            2. FISH or culture of trophoblastic cells
         10. Percutaneous umbilical blood sampline
             1. Diagnosis of fetal RBC alloimmunization (Rh reaction)
         11. Cell-free Fetal DNA testing
             1. Detects aneuploidy
             2. Not sensitive/specific enough to be considered diagnostic
         12. 2nd Trimester Quad Screen
             1. alpha-fetoprotein
             2. beta-hCG
             3. estriol
             4. inhibin A
         13. Biophysical Profile of Pregnancy
             1. Score <= 6/10
             2. Delivery should be considered
             3. Score <= 2/10
             4. Delivery should be performed
         14. Considered the gold standard (>99.9% accuracy)
      2. Estimated Date of Confinement (Due Date)
         1. 40 weeks from previous menstrual period
         2. 40 week gestation as determined by ultrasound imaging
      3. Nutritional Considerations
         1. Calcium and iron are major minerals needed by fetus
            1. Adequate dietary calcium intake is generally sufficient
            2. Iron supplementation is necessary
      4. Emesis Gravidarum (Morning Sickness)
         1. Treatment
            1. Doxylamine
            2. Pyridoxine
            3. Avoidance of food triggers
            4. Frequent, small meals
         2. Occurs in 70% of pregnancies
      5. Hypertension in Pregnancy
         1. Chronic hypertension
            1. Hypertension before pregnancy or < 20 weeks of gestation / >12 weeks postpartum
         2. Gestational Hypertenstion
         3. Preeclampsia
            1. Diagnostic Criteria
            2. BP > 140/90 mmHg
            3. Proteinuria >= 300 mg/24 hours
            4. Protein/creatinine >= 0.3
            5. Urine dipstick protein >= 1
            6. Management of Preeclampsia
            7. Short-term Management
            8. Management of HELLP Syndrome
            9. >= 34 weeks of gestation
            10. Immediate delivery of fetus (after maternal stabilization)
            11. < 34 weeks of gestation
            12. Delay delivery <= 48 hours for administration of steroids
            13. Long-term Management
            14. Patients should receive yearly cardiovascular and metabolic assessments
            15. Severe preeclampsia
            16. Diagnostic Criteria
            17. Systolic BP >= 160 mmHg
            18. Diastolic BP > 110 mmHg
            19. End-organ damage
            20. 2 measurements > 4 hours apart
            21. 2 measurements > 4 hours apart
      6. Special Considerations
         1. Patients with hypertension
            1. Strict blood pressure control
            2. Pharmacological treatment
            3. Calcium channel blockers or beta-blockers
            4. ACE-Is are contradindicated
         2. Patients with heart failure
            1. High-risk time points
            2. 32 weeks
            3. Peak cardiac output during pregnancy
            4. During labor
            5. Spike in cardiac output (due to stress/exertion)
            6. Immediately postpartum period
            7. Uterine vessels clamp down to return blood to maternal circulation
   5. Labor and Delivery
      1. Preterm Labor and Delivery
         1. Prevention of Preterm Labor
            1. Indications
            2. History of preterm labor
            3. Short cervix
            4. Cervical insufficiency
            5. Treat with progesterones
            6. Treat with cervical cerclage
         2. Clinical Signs of Preterm Labor
            1. >= 6 conctrations/hour
            2. Progressive cervical change
            3. Cervical dilation
            4. Cervical effacement
            5. Fetal fibronectin on vaginal swab
            6. Suggests preterm labor
            7. Rules out preterm labor
         3. Pharmaceutical Management of Preterm Labor
            1. Tocolytic drugs
            2. Initial administration
            3. Repeat administration
            4. Contraindicated in patients with premature rupture of membranes
            5. Risk of cerebral palsy with > 1 repeat administration
            6. Anitbiotics
            7. Steroids
            8. Should be administered 1-7 days before delivery for optimal benefit
         4. Risk Factors for Preterm Birth
            1. Multiple gestation pregnancies (twins, triplets, etc.)
            2. Uterine distention and other factors
            3. Associated with IVF treatment
            4. Reproductive tract anatomic abnormalities
            5. Low socioeconomic status
            6. Poor nutrition
            7. Lack of prenatal care
            8. Smoking
            9. Young age or older age
            10. Infection
            11. Assisted reproductive technology
         5. Management of Severe Preeclampsia in Preterm Infants
            1. Immediate delivery (after maternal stabilization) if >34 weeks
            2. Close monitoring and delivery if maternal complications if 24-32 weeks
      2. Delivery Techniques
         1. Vertex
            1. External Cephalic
         2. Nonvertex (Vaginal Breech Extraction)
            1. Internal Podalic
         3. Cesarean Section
            1. Low Transverse Cesarean
      3. Complications of Labor and Delivery
         1. Hemorrhage
   6. Management of Menopause
      1. Major Sequelae of Ovarian Failure
         1. Vasomotor symptoms (hot flashes)
         2. Urogenital atrophy
         3. Osteoporosis
         4. Breast changes
         5. Sense of well-being
      2. Indications for treatment of low bone density
         1. Osteoporotic fracture
         2. Osteoporosis (T-score < -2.5)
         3. Osteopenia (T-score < -1) and > 20% fracture risk at 10 years (>3% hip risk)
      3. Hormonal Therapy for Menopause
   7. Contraception
   8. Termination of Pregnancy
      1. Methods of Inducing Abortion
         1. Medication Abortion
         2. Dilation and Curettage with Vacuum Suction
            1. Manual suction
            2. Electric suction
         3. Dilation and Evacuation
         4. Induction Abortion
            1. Misoprostol
            2. Mifepristone
            3. Common side effects
            4. Low grade fever
            5. Nausea and vomiting
            6. Diarrhea
            7. Chills
            8. Abdominal pain
            9. Major causes of morbidity and mortality
            10. Infection
            11. Hemorrhage
            12. Incomplete abortion
            13. Mechanical Injury
            14. Anesthetic complications
      2. Access to Abortions
         1. Mandatory 72 hour waiting period
         2. Mandatory parental consent for minors
         3. Medicaid does not cover elective abortions
   9. Multiple Gestations
      1. Dizygotic
      2. Monozygotic
      3. Timeline of Twinning and Placentation
         1. Days 1-4
            1. Diamnionic dichorionic (DiDi)
            2. "Twin Peak" or lambda sign on fetal ultrasound
         2. Days 4-8
            1. Diamnionic monochorionic (DiMo)
            2. "T sign" on fetal ultrasound
         3. Days 8-12
            1. Monoamnionic monochorionic (MoMo)
         4. Days 12-16
            1. Conjoined
      4. Physiologic Differences from Singleton Gestation
         1. Larger increase in blood volume
         2. Larger increase in cardiac output
         3. Larger increase in heart rate
         4. Larger decrease in blood pressure
      5. Prenatal Management in Multiple Gestation Pregnancies
         1. Prenatal Diagnostic Tests
            1. Serum Screening
            2. Nuchal Translucency Measurement
            3. Chorionic Villus Sampling
            4. Amniocentesis
            5. Higher risk of pregnancy loss compared to singletons
         2. Nutrtional and Dietary Recommendations
            1. Daily caloric intake
            2. Weight gain per week
            3. Iron and folate intake
         3. Blood pressure monitoring
         4. fetal ultrasounds
         5. Non-stress tests or biophysical profiles
      6. Labor and Delivery
         1. Dichorionic Twins
            1. Ideally delivered at 38 weeks
            2. Delivery sequence
            3. 1st baby
            4. 2nd baby
            5. Placentas 1 and 2
         2. Monochorionic Twins
            1. Admit at 28-30 weeks and administer steroids
            2. Ideally delivered between 32-36 weeks
      7. Complications of Multiple Gestation Pregnancies
         1. Major Increased Maternal Risks
            1. Gestational diabetes
            2. Placental abruption
            3. Anemia
            4. Post-partum hemorrhage
            5. Pre-eclampsia
         2. Major Increased Fetal Risks
            1. Preterm labor rate
            2. average birth weight
            3. rate of NICU admission
            4. Risk of aneuploidy
            5. Handicap/cerebral palsy risk
            6. risk of death in 1st year
         3. Risks to surviving twin if co-twin is lost
            1. 1st trimester
            2. No increased risk
            3. 2nd trimester
            4. Risk
            5. 3rd trimester
            6. Risk
            7. Even higher if monochorionic (vs. dichorionic)
         4. Twin-Twin Transfusion Syndrome (TTTS)
            1. Quintero Staging System
            2. Ultrasoud Parameter
            3. Amniotic fluid discordance
            4. Fetal Bladder
            5. Abnormal Doppler studies
            6. Hydrops
            7. Absent cardiac activity
            8. Criteria
            9. MVP < 2 cm in donor; MVP > 8 cm in recipient
            10. Nonvisualization of fetal bladder in donor twin over 60 minutes
            11. Absent/reversed UA diastolic flow, reversed A wave in ductus venosus, pulsatile flow in UV
            12. Hydrops in one or both twins
            13. Fetal demise in one or both twins
            14. Prognosis
            15. 75% are stable or regress
            16. Preinatal loss rate: 70-100%
            17. Preinatal loss rate: 70-100%
            18. Preinatal loss rate: 70-100%
            19. Causes 50% of diamniotic monochorionic twin mortality
            20. Management of TTTS
            21. Screen with ultrasound every 2 weeks from week 16 until delivery
            22. Measure fetal growth with ultrasound every 4 weeks
            23. Use doppler studies if fetal growth abnormalities or ambiotic fluid discrepancy identified
            24. Do fetal echocardiogram for all MC/DA twin gestations
            25. Antenatal surveillance
            26. Treatment
            27. Fetoscopic Laser Coagulation
            28. Amnioreduction
            29. Selective reduction
            30. Intentional septostomy
         5. Twin Anemia Polycythemia Sequence (TAPS)
            1. Treatment
            2. Delivery (depending on gestational age)
            3. Intrauterine fetal transfusion
            4. Fetocide
            5. Repeat Fetoscopic Laser Coagulation
4. Diseases and Disorders
   1. Primary Diseases of the Female Reproductive System
      1. Congenital Anomalies of the Female Genitalia
         1. Congenital Uterine Abnormalities
            1. Uterine hypoplasia/agenesis
            2. Unicornuate uterus
            3. Didelphic uterus
            4. Complete failure of fusion
            5. Double uterus, vagina, and cervix
            6. Prenancy possible
            7. Bicornuate uterus
            8. Incomplete fusion of Mullerian ducts
            9. Increased risk of complicated pregnancy
            10. Septate uterus
            11. Common anomaly
            12. Incomplete resorption of septum
            13. Decreased fertility
            14. Septoplasty
            15. Arcuate uterus
            16. T-shaped uterus
            17. Etiology
            18. Drug-induced
            19. Diethystilbestrol (DES)
         2. Mullerian Agenesis
            1. Mayer-Rokitansky-Kuster-Hauser (MRKH) Syndrome
            2. Absence of uterus, cervix, and/or vagina
            3. Failure of the Mullerian duct to develop
      2. Fallopian Tube Dysfunction and Disease
         1. Fallopian Tube obstruction
            1. Hematosalpinx
            2. Pyosalpinx
            3. Hydrosalpinx
      3. Ovarian Dysfunction and Disease
         1. Anovulation
            1. Lack of progesterone secondary to failure of corpus luteum formation
            2. Etiologies
            3. Pregnancy
            4. Polycystic ovarian syndrome
            5. Obesity
            6. HPO-axis abnormalities
            7. Premature ovarian failure
            8. Hyperprolactinemia
            9. Thyroid disorders
            10. Eating disorders
            11. Competitive athletes
            12. Cushing syndrome
            13. Adrenal insufficiency
            14. Endometrial breakdown with gland proliferation
         2. Poor/diminished ovarian reserve
            1. Low fertility
            2. Due to diminished number of oocytes/impaired oocyte development or recruitment
            3. Natural decline with age
            4. Genetic ovarian insufficiency
            5. Autoimmune disease
            6. Adrenal impairment
            7. Iatrogenic damage to ovary
         3. Ovarian hyperstimulation syndrome
            1. Occurs in women taking fertility medication to stimulate egg growth
            2. VEGF levels
            3. capillary permeability
            4. Distributive shock
            5. Enlarged, painful ovaries
            6. Ascites
            7. May require paracentesis
         4. Ovarian neoplasms
            1. Hereditary or germline
            2. Etiology
            3. Autosomal dominant mutations in DNA mismatch repair genes
            4. BRCA1
            5. BRCA2
            6. Most common adnexal mass in women > 55 years old
            7. Protective Factors
            8. Oral contraceptives
            9. Tubal ligation/Salpingectomy
            10. Pregnancy
            11. Breast feeding
            12. Surface epithelial tumors
            13. Germ cell tumors
            14. Sex cord stromal tumors
      4. Endometrial Dysfunction and Disease
         1. Endometritis
            1. Acute Endometritis
            2. Neutrophils
            3. Chronic Endometritis
            4. Plasma cells
            5. More common than acute endometritis
            6. Etiologies
            7. Foreign bodies
            8. Instrumentation
            9. IUD
            10. Necrotic/inflamed tissues
            11. Pelvic inflammatory disease
            12. Torsed polyp
            13. Retained products of conception
            14. Outlet obstruction
            15. Cervical stenosis
            16. Myomas
            17. Endometrial actonomycosis
            18. Actinomyces israelii
            19. Sulfur granules
            20. Associated with IUD implantation
            21. Antibiotics
            22. Gentamicin
            23. Clindamycin
            24. +/- ampicillin
         2. Endometriosis
         3. Endometrial polyp
            1. Fibrotic stroma
            2. Abnormal glands
            3. Thickened blood vessels
            4. Endometrial intraepithelial carcinoma
         4. Atrophic endometrium
            1. Histologic features
            2. Thin endometrium
            3. Glands lined by single layer of cells
            4. No mitotic figures
            5. Sparse glands
            6. Dense, spindled stroma
            7. Inactive endometrium due to lack of stimulation by sex hormones
            8. Post-menopausal patients
            9. Post-oophorectomy patients
            10. Drug-induced
            11. GnRH agonists
         5. Endometrial Neoplasms
            1. Pre-invasive neoplastic processes
            2. Endometrial hyperplasia
            3. Postmenopausal uterine bleeding
            4. Excess estrogen stimulation
            5. Obesity
            6. Polycystic Ovary Syndrome
            7. Estrogen replacement
            8. WHO Classification
            9. Simple non-atypical
            10. 1%
            11. Simple atypical
            12. 8%
            13. Complex non-atypical
            14. 3%
            15. Complex atypical
            16. 29%
            17. Endometrial intraepithelial carcinoma
            18. Endometrial Carcinoma
            19. Postmenopausal uterine bleeding
            20. Histological Classification
            21. Endometrioid Adenocarcinoma (Type 1)
            22. Peri/post-menopausal
            23. Usually low
            24. Endometroid, mucinous
            25. More often superficial
            26. Usually good
            27. PTEN activation
            28. 80%
            29. Endometrial hyperplasia (hyperplasia pathway)
            30. Serous adenocarcinoma (Type 2)
            31. 20%
            32. TP53 mutation
            33. Usually poor
            34. More likely deep
            35. Serous, clear cell
            36. Always high
            37. Post-menopausal
            38. Endometrial intraepithelial carcinoma (sporadic pathway)
            39. Treatment of Endometrial Cancer
            40. Initial Treatment
            41. Hysterectomy (including tubes and ovaries)
            42. Pelvic washing
            43. Lymph node dissection
            44. Adjuvant Therapy
            45. Vaginal brachytherapy
            46. Chemotherapy
            47. Pelvic radiation
            48. Most common invasive carcinoma of the female genital tract
            49. Risk Factors
            50. Use of estrogen without progestins
            51. Obesity
            52. Hypertension
            53. Nulliparity
            54. Late menopause
            55. Diabetes
            56. Lynch Syndrome
         6. Asherman's Syndrome
            1. Characterized by adhesions/synechiae and/or fibrosis of the endometrium
            2. Trauma
            3. Most commonly associated with dilation and curettage of the intrauterine cavity
            4. Treatment
            5. Surgical excision
            6. Hormone therapy
      5. Perineal Lacerations
         1. Associated with vaginal delivery
         2. Classification
            1. 1st degree
            2. Laceration limited to vaginal mucosa or skin
            3. 2nd degree
            4. Laceration also involves subcutaneous tissue
            5. 3rd deggree
            6. Laceration also involves sanal sphincter
            7. 4th degree
            8. Laceration also involves rectal mucosa
   2. Secondary Diseases of the Female Reproductive System
      1. Diseases of the Endocrine System
         1. Diseases of the Hypothalamic/Pituitary/Ovarian Axis
            1. Hypothalamic Disease
            2. Anterior Pituitary Gland Disease
            3. Hyperpituitarism
            4. Prolactin-secreting pituitary adenomas
            5. Treatment
            6. Dopamine agonists
            7. Bromocriptine
            8. Cabergoline
            9. Surgical excision
            10. Classification
            11. Microadenoma
            12. Macroadenoma
            13. Hypopituitarism
            14. Thyroid Disease
            15. Adrenal Disease
            16. Gonadal Disease
            17. Polycystic Ovarian Syndrome
            18. Hormonal hypothalamic disturbances cause FSH/LH imbalance
            19. Androgen production by theca cells
            20. Inhibition of follicular maturation and ovulation
            21. Premature Ovarian Failure (Primary Ovarian Insufficiency)
            22. Menopause before age 40
            23. Estrogen
            24. FSH and LH
   3. Pregnancy-associated Diseases and Disorders
      1. Pregnancy with abortive outcome
         1. Ectopic pregnancy
            1. Treatment
            2. Surgery
            3. Methotrexate
         2. Hydatidiform mole
            1. Abnormal conception with cystic swelling of chorionic villi and trophoblastic proliferation
            2. Swollen and edematous villi
            3. Proliferation of trophoblasts
            4. hCG-mediated sequelae
            5. Early preeclampsia
            6. Theca-lutein cysts
            7. Hyperemesis gravidarum
            8. Hyperthyroidism
            9. Vaginal bleeding
            10. Greater than expected uterine enlargement
            11. Pelvic pressure/pain
            12. Subtypes
            13. Karyotype
            14. 46,XX; 46,XY
            15. 69,XXX; 69,XXY; 69,XYY
            16. Components
            17. Enucleated egg fertilized by two sperm
            18. Enucleated egg fertilized by one sperm + duplication of paternal chromosomes
            19. Normal ovum fertilized by two sperm
            20. Normal ovum fertilized by one sperm + duplication of paternal chromosomes
            21. Fetal Tissue
            22. Absent
            23. Present
            24. Villous edema
            25. Most villi are hydropic
            26. Some villi are hydropic and others are normal
            27. Trophoblastic proliferation
            28. Diffuse, circumferential proliferation around hydropic villi
            29. Focal proliferation present around hydropic villi
            30. hCG
            31. (but less than complete mole)
            32. Uterine Size
            33. Imaging
            34. "Honeycombed" uterus or "clusters of grapes"/"snowstorm" on ultrasound
            35. Fetal parts
            36. Risk of malignancy (gestational trophoblastic neoplasia)
            37. 15-20%
            38. < 5%
            39. Risk of choriocarcinoma
            40. 2%
            41. Rare
            42. Treatment
            43. (Suction) Dilation and curettage
            44. Methotrexate
            45. Post-removal beta-hCG surveillance
         3. Abortion (pregnancy loss)
            1. Spontaneous abortion (miscarriage)
            2. Choromosomal abnormalities
            3. Trisomy 16
            4. Most common trisomal cause of early pregnancy loss
            5. Trisomy 13
            6. Trisomy 18
            7. 45X (Turner's Syndrome)
            8. Most common chromosomal abnormality in abortuses
            9. Trisomy 21
            10. Extremely high loss rate (>95%)
            11. Fetal loss before 20 weeks of gestation
      2. Gestational trophoblastic neoplasia
         1. Status of pregnancy
            1. % of Cases
            2. 50%
            3. 25%
            4. 25%
         2. Hydatidiform mole
            1. Abnormal conception with cystic swelling of chorionic villi and trophoblastic proliferation
            2. Swollen and edematous villi
            3. Proliferation of trophoblasts
            4. hCG-mediated sequelae
            5. Early preeclampsia
            6. Theca-lutein cysts
            7. Hyperemesis gravidarum
            8. Hyperthyroidism
            9. Vaginal bleeding
            10. Greater than expected uterine enlargement
            11. Pelvic pressure/pain
            12. Subtypes
            13. Karyotype
            14. 46,XX; 46,XY
            15. 69,XXX; 69,XXY; 69,XYY
            16. Components
            17. Enucleated egg fertilized by two sperm
            18. Enucleated egg fertilized by one sperm + duplication of paternal chromosomes
            19. Normal ovum fertilized by two sperm
            20. Normal ovum fertilized by one sperm + duplication of paternal chromosomes
            21. Fetal Tissue
            22. Absent
            23. Present
            24. Villous edema
            25. Most villi are hydropic
            26. Some villi are hydropic and others are normal
            27. Trophoblastic proliferation
            28. Diffuse, circumferential proliferation around hydropic villi
            29. Focal proliferation present around hydropic villi
            30. hCG
            31. (but less than complete mole)
            32. Uterine Size
            33. Imaging
            34. "Honeycombed" uterus or "clusters of grapes"/"snowstorm" on ultrasound
            35. Fetal parts
            36. Risk of malignancy (gestational trophoblastic neoplasia)
            37. 15-20%
            38. < 5%
            39. Risk of choriocarcinoma
            40. 2%
            41. Rare
            42. Treatment
            43. (Suction) Dilation and curettage
            44. Methotrexate
            45. Post-removal beta-hCG surveillance
         3. Choriocarcinoma
            1. Malignancy of trophoblastic tissue
            2. Cytotrophoblasts
            3. Syncytiotrophoblasts
            4. Hematogenous spread to lungs
            5. Absence of chorionicvilli
            6. frequency of bilateral/multiple theca-lutein cysts
            7. Abnormally increased beta-hCG
            8. Shortness of breath
            9. Hemoptysis
      3. Chorioamnionitis
         1. Fever
         2. Uterine tenderness
         3. Maternal tachycardia
      4. Preeclampsia
         1. Disruption of trophoblastic remodeling of spiral arteries
            1. Abnormal placental spiral arteries
            2. Endothelial dysfunction
            3. Vasospasm (vasoconstriction)
            4. Inflammation
         2. High blood pressure
         3. Proteinuria
         4. Severe headache
            1. due to impaired cerebral autoregulation (vasospasm)
         5. Complications of Preeclampsia
            1. Placental abruption
            2. Coagulopathy
            3. Renal failure
            4. Uteroplacental insufficiency
            5. Eclampsia
            6. Seizures
            7. Complications of Eclampsia
            8. Stroke
            9. Intracranial hemorrhage
            10. Adult Respiratory Distress Syndrome
            11. Can cause maternal death
            12. Treatment
            13. Antihypertensives
            14. IV magnesium sulfate
            15. Immediate delivery of fetus
            16. HELLP Syndrome
            17. Hemolysis
            18. Elevated liver enzymes
            19. Low platelets
            20. Elevated LDH
            21. Schistocytes on peripheral smear
            22. Treatment
            23. >= 34 weeks of gestation
            24. Immediate delivery of fetus (after maternal stabilization)
            25. < 34 weeks of gestation
            26. Delay delivery <= 48 hours for administration of steroids
         6. Treatment
            1. Antihypertensives
            2. IV magnesium sulfate
            3. Delivery of fetus
         7. Risk of recurrence = 40% in patients with severe or early onset preeclampsia
      5. Gestational hypertension
         1. High blood pressure
         2. Treatment
            1. Antihypertensives
            2. Hydralazine
            3. alpha-Methyldopa
            4. Labetalol
            5. Nifedine
            6. Delivery of fetus at 37-39 weeks
      6. Hyperemesis Gravidarum
         1. Etiology
            1. Hormonal
            2. hCG
            3. Progesterone
         2. Severe nausea and vomiting
         3. Weight loss
         4. Dehydration
         5. Transient hyperthyroidism
         6. Treatment
            1. IV hydration
            2. Anti-emetics
            3. Prochlorperazine
            4. Chlorpromazine
            5. Promethazine
            6. Metoclopramide
            7. Ondansetron
            8. NPO for 24-48 hours
            9. Gastric acid suppression
            10. Enteral tube feeding
            11. Total parenteral nutrition
         7. Associated with pre-existing psychiatric conditions
            1. Depression
            2. Anxiety
            3. Eating disorders
            4. Conversion disorders
      7. Placental Abruption
      8. Placenta Previa
   4. Congenital Disorders
      1. Chromosomal Abnormalities
         1. Aneuploidies
            1. Patau Syndrome
            2. Trisomy 13
            3. Signs and Symptoms
            4. Severe intellectual disability
            5. Rocker-bottom feet
            6. Microphthalmia
            7. Microcephaly
            8. Cleft lip/palate
            9. Holoprosencephaly
            10. Polydactyly
            11. Congenital heart disease
            12. Cutis aplasia
            13. Edwards Syndrome
            14. Trisomy 18
            15. Signs and Symptoms
            16. Severe intellectual disability
            17. Rocker-bottom feet
            18. Micrognathia
            19. Low-set ears
            20. Clenched hands with overlapping fingers
            21. Prominent occiput
            22. Congenital heart disease
            23. Down Syndrome
            24. Trisomy 21
            25. Meiotic nondisjunction
            26. 95%
            27. 47,xx,+21 (females) 47,XY,+21 (males0
            28. Unbalanced Robertsonian translocation
            29. 3-4%
            30. 46,xx,t(14q21q) (females) 47,XY,(14q21q) (males0
            31. Mosaicism due to post-fertilization mitotic error
            32. 1-2%
            33. Signs and Symptoms
            34. Fetal Features
            35. Nuchal translucency
            36. Thickened nuchal fold
            37. Hypoplastic nasal bone
            38. Duodenal Atresia
            39. Congenital heart disease
            40. Atrioventricular septal defect (endocardial cushin defect)
            41. Atrial septal defect
            42. Ventricular spetal defect
            43. Neonatal Features
            44. Hypotonia
            45. Flat facies
            46. Upslanted palpebral fissures
            47. Wide space between first 2 toes
            48. Single palmar crease
            49. Associated conditions
            50. Early-onset Alzheimer's Disease
            51. ALL and AML
            52. Most common viable chromosomal disorder
            53. Most common cause of genetic intellectual disability
            54. 1:700 births
            55. Sex Chromosome Aneuploidies
            56. Turner Syndrome
            57. 45X
            58. Most common cause of primary amenorrhea
            59. Anatomic abnormalities
            60. Short stature
            61. Ovarian dysgenesis
            62. Webbed neck
            63. Cystic hygromas
            64. Lymphedema
            65. Bicuspid aortic valve
            66. Aortic coarctation
            67. Horshoe kidney
            68. Yes
            69. No
            70. Klinefelter's Syndrome
            71. 47,XXY
            72. Dysgenesis of seminiferous tubules
            73. Inhibin B
            74. FSH
            75. Abnormal Leydig cell function
            76. testosterone
            77. LH
            78. estrogen
            79. Testicular atrophy
            80. Gynecomastia
            81. Female hair distribution
            82. Developmental delay
            83. No
            84. Yes
            85. Common cause of hypogonadism
            86. XYY Syndrome
            87. 47,XYY
            88. Yes
            89. Yes
            90. Severe acne
            91. Learning disorders
            92. Autism spectrum disorders
            93. XXXY Syndrome
            94. 48,XXXY
            95. Yes
            96. Yes
            97. 49, XXXXY Syndrome
            98. 49, XXXXY
            99. Yes
            100. Yes
            101. Quadruple X Syndrome/Pentasomy X
            102. 48, XXXX/49, XXXXX
            103. No
            104. Yes
      2. Neural Tube Defects
         1. Neuropores fail to fuse during 4th week of development
            1. Persistent connection between amniotic cavity and spinal canal
         2. Associated with low folate intake before conception and during pregnancy
            1. Neural tube defects are effectively prevented with daily folate supplementation
         3. Spina bifida occulta
            1. No herniation
            2. Associated with tuft of hair or skin dimple at level of bony defect
         4. Meningocele
            1. Only meninges herniate through bony defect
         5. Meningomyelocele
            1. Meninges and neural tissue herniate through bony defect
   5. Gynecological Neoplasia
      1. Gestational trophoblastic neoplasia
      2. Endometrial neoplasia
         1. Endometrial carcinoma
      3. Ovarian neoplasia
5. OBGYN Treatments
   1. Vitrification
      1. Oocyte vitrification
         1. Cryopreservation of oocytes
      2. Embryo vitrification
         1. Cryopreservation of spare embryos
   2. Cervical cerclage
   3. Caeserean Section (C-section)
   4. Episiotomy
   5. Dilation and Curettage
   6. Treatment of Neoplasia
      1. Treatment of Cervical Cancer
         1. Early Treatment
            1. Microinvasive cervical cancer
            2. Conization
            3. Simple hysterectomy
            4. Invasive cervical cancer
            5. Radical hysterectomy
            6. Chemoradiation
      2. Treatment of Ovarian Cancer
         1. Adjuvant chemotherapy
            1. Carboplatin
            2. Paclitaxel (taxols)
   7. In Vitro Fertilization (IVF)
      1. Controlled ovarian hyperstimulation
      2. Egg retrieval
      3. Intracytoplasmic sperm inject (ICSI)
      4. Pronucleus of sperm enters ovum
      5. Fusion of genetic material
      6. Embryo transfer
   8. Hormonal Therapy for Menopause
      1. Indications
         1. Relief or prevention of menopausal symptoms
            1. Hot flashes
            2. Vaginal atrophy
         2. Osteoporosis
      2. Associated risks
         1. Breast cancer
            1. Progesterone-mediate mechanism
         2. Endometrial cancer
         3. Venous thromboembolism
         4. Coronary heart disease
         5. Stroke
         6. Roughly equivalent mortality
      3. Formulations
         1. Estrogen-only
            1. Patients without a uterus
         2. Estrogen + progestin
         3. Local estrogen therapy (cream, tablet, ring)
   9. Contraception
      1. Oral Contraceptives (OCPs)
         1. Most commonly used form of reversible contraception in the US
         2. Progestins
         3. Ethinyl estradiol
         4. Major Risks of Combined Hormal Contraception
            1. Venous thromboembolism
            2. Arterial thrombotic events
            3. Myocardial infarction
            4. Cerebrovascular accident
            5. Hypertension
            6. Liver adenoma
            7. Contraindications
            8. Patients at increased risk of cardiovascular disease
            9. History of thrombosis
            10. Hypertension
            11. Smoking (> 35 years old)
            12. Migraines (with aura)
            13. History of/active breast cancer
            14. Diabetes (with end organ disease)
            15. Active hepatic disease
      2. Vaginal Ring
      3. Transdermal patch
      4. Intrauterine Devices (IUDs)
         1. Copper IUD
            1. Mechanism
            2. Impairment of sperm function
            3. Produces local inflammation reaction toxic to sperm and ova
            4. Prevents fertilization and implantation
            5. Contraindications
            6. Active pelvic inflammation
            7. Side effects
            8. Heavier or longer menses
            9. Dysmenorrhea
            10. Risk of PID with insertion
            11. Indications
            12. Long-acting reversible contraception
            13. Emergency contraception
         2. Levonorgestrel intrauterine system (LNG-IUS)
            1. Mechanism
            2. Releases a small amount of progesterone every day
            3. Side effects
            4. Risk of PID with insertion
      5. Injectable Depot Medroxyprogesterone Acetate (Depo-Provera)
         1. Medroxyprogesterone
         2. Mechanism
            1. Releases a small amount of progesterone every day
      6. Subdermal Implant
         1. Etonogestrel
         2. Mechanism
            1. Releases a small amount of progesterone every day
      7. Condoms and Diaphragms
         1. Mechanism
            1. Physical blockade between sperm and ova
         2. Contraindications
            1. Latex allergy
         3. Side effects
      8. Sterilization
         1. Elective Female Sterilization
            1. Tubal sterilization
            2. Mechanism
            3. Physical blockade between ovary and uterus
            4. Tubal Ring
            5. Tubal Clip
            6. Bipolar Coagulation
            7. Hysteroscopic occlusion
            8. Mechanism
            9. Physical blockade between ovary and uterus
            10. Essure Micro-Insert
            11. Major Risks of Female Sterilization
            12. Surgical complications
            13. Ectopic pregnancy
            14. Regret
         2. Elective Male Sterilization
            1. Vasectomy
      9. Lactational Amenorrhea
         1. Mechanism
            1. Inhibits ovulation
            2. Inhibition of GnRH and LH release
      10. Emergency Contraception
          1. Levonorgestrel (pill)
          2. Ulipristal (pill)
          3. Copper IUD
          4. Delay ovulation
          5. Interferes with sperm function
   10. Pharmaceutical Treatments
       1. Selective Estrogen Receptor Modulators (SERMs)
          1. Clomiphene citrate
             1. Mechanism
             2. Inhibition of hypothalamic estrogen receptor
             3. Reduction of negative feedback on GnRH production
             4. GnRH secretion
             5. Side effects
             6. Hot flashes
             7. Ovarian enlargement
             8. Multiple simultaneous pregnancies
             9. Visual disturbances
             10. Indications
             11. Infertility
       2. Gonadotropins (human or recombinant)
          1. Direct stimulation of ovaries
          2. Human Chorionic Gonadotropin (hCG)
             1. Mechanism
             2. Activation of LHCGR
             3. Ovulation via LH mimicry
             4. Indications
             5. Infertility
          3. Menotropin
       3. GnRH Agonists
          1. Leuprolide
             1. Mechanism
             2. Indications
             3. Infertility
             4. Uterine fibroids
             5. Endometriosis
             6. Precocious puberty
             7. Prostate cancer
       4. FSH Analogues
          1. Recombinant FSH
       5. Tocolytics
          1. Magnesium sulfate
             1. Mechanism
             2. Indications
             3. Preterm labor
             4. First line treatment for gestational ages < 30 weeks
             5. Protects from cerebral palsy
             6. Contraindications
             7. Cautious use in patients with renal impairment
          2. Calcium channel blockers
             1. Nifedipine
             2. Mechanism
             3. Side effects
             4. Risk of hypotension if co-administered with magnesium sulfate
             5. Indications
             6. Preterm labor
             7. Contraindications
          3. NSAIDs
             1. Indomethacin
             2. Mechanism
             3. Indications
             4. Preterm labor
             5. Contraindications
             6. Side effects
             7. Amniotic fluid
             8. Premature ductus arteriosus closure
       6. Antibiotics
       7. Steroids
          1. Progestins
             1. Levonorgestrel
             2. Medroxyprogesterone
             3. Etonogestrel
             4. Norethindrone
             5. Megestrol
             6. Mechanism
             7. Thins endometrium
             8. Growth
             9. Vascularization
             10. Thickens cervical mucus
             11. Impairs tubal mobility
             12. Inhibits ovulation
             13. Inhibition of GnRH and LH release
             14. Side effects
             15. Amenorrhea and irregular bleeding (when progestin-only)
             16. Indications
             17. Contraception
             18. Progestin-only
             19. Progestin-only pill
             20. Injectable Depot Medroxyprogesterone Acetate (Depo-Provera)
             21. Levonorgestrel intrauterine system (LNG-IUS)
             22. Subdermal Implant
             23. Progestin and estrogen
             24. Combined oral contraceptives
             25. Abnormal uterine bleeding
             26. Progestin challenge
             27. Endometrial cancer
             28. Contraindications
             29. Breast cancer
             30. Liver disease
          2. Estrogen
             1. Mechanism
             2. Suppression of ovarian hormone production
             3. Side effects
             4. Indications
       8. Bisphosphonates
          1. Alendronate, ibandronate, risedronate, zoledronate
          2. Mechanism
             1. Inhibit osteoclast activity
          3. Side effects
             1. Short-term
             2. Esophagitis/gastritis
             3. Osteonecrosis of jaw
             4. Long-term
             5. Atypical stress fractures (chalky bone phenomenon)
          4. Indications
             1. Osteoporosis
             2. Hypercalcemia
             3. Paget disease of bone
             4. Metastatic bone disease
             5. Osteogenesis imperfecta
       9. Selective Estrogen Receptor Modulators (SERMs)
          1. Tamoxifen
             1. Mechanism
             2. Estrogen receptor antagonist in breast and agonist in bone
             3. Blocks binding of estrogen to ER+ cells
             4. Partial agonist in endometrium
             5. risk of endometrial cancer
             6. Side effects
             7. Associated risks
             8. Endometrial cancer
             9. Thromboembolic events
             10. Deep vein thrombosis
             11. Pulmonary embolism
             12. Indications
             13. Osteoporosis
             14. Breast cancer treatment and prevention
          2. Raloxifene
             1. Mechanism
             2. Estrogen receptor antagonist in breast and agonist in bone
             3. Blocks binding of estrogen to ER+ cells
             4. Antagonist in endometrium
             5. No increased risk of endometrial cancer
             6. Side effects
             7. Associated risks
             8. Thromboembolic events
             9. Deep vein thrombosis
             10. Pulmonary embolism
             11. Indications
             12. Osteoporosis
       10. Antiprogestins
           1. Mifepristone
              1. Indications
              2. Termination of pregnancy
           2. Ulipristal
              1. Indications
              2. Emergency contraception
           3. Mechanism
              1. Competitive inhibitors of progestins at progesterone receptors
       11. PGE1 Analogues
           1. Misoprostol
           2. Mechanism
              1. Stimulation of myometrial contractions
              2. Cervical ripening
           3. Side effects
              1. Diarrhea
           4. Indications
              1. Labor induction
              2. Abortion
              3. Post-partum bleeding
              4. Gastric ulcer prevention
           5. Contraindications
              1. Pregnancy
       12. Antifolates
           1. Methotrexate
           2. Mechanism
              1. Competitive inhibition of dihydrofolate reductase
              2. Inhibition of DNA, RNA, thymidylates, and protein synthesis
           3. Side effects
           4. Indications
              1. Ectopic Pregnancy
           5. Contraindications